Exploring the impact of COVID-19 on families of children with developmental disabilities: A community-based formative study

Background

COVID-19 continues to disproportionately impact families of children with developmental disabilities (DD). There is an urgent need to understand these families' experiences, particularly those that face economic or social marginalization. This qualitative study sought to identify the experiences of families of children with DD during the COVID-19 pandemic.

Methods

Using phenomenology, in-depth interviews (IDIs) were conducted with caregivers and health care providers of children with DD living in a large urban Canadian city. Interviews were recorded, transcribed, and coded using inductive coding methods by two independent coders. Transcripts were analyzed within and across stakeholder groups using thematic analysis.

Results

A total of 25 IDIs were conducted in 2020. 3 main themes and 7 sub-themes emerged related to the experiences of parents and health care providers for children with DD: families reported difficulty adhering to public health measures leading to isolation and increased parental stress; restricted access to in-person services worsened behaviour and development; and worsened household financial security in already marginalized families.

Conclusions

Our study demonstrates that families of children with DD have been negatively impacted by the evolving environment from the COVID-19 pandemic, and even more so in those who face social and economic challenges. Public health restrictions have impaired the daily lives of these families and our study suggests that limitations to accessing in-person services may have long-lasting impacts on the well-being of families of children with DD. It is imperative that the unique needs of these families be considered and centred for future interventions.

Virtual breakout rooms: an effective approach to offer guidance to medical students on residency applications

Peer mentorship on residency applications has been difficult due to recent public health measures, prompting a shift from in-person events to virtual platforms. To address gaps in career exploration, we created a virtual, non-recorded space that allowed medical students and residents to discuss the Canadian Resident Matching Service (CaRMS) process meaningfully and transparently. Attendees reported a greater understanding of the match process and reduced anxiety after the event. This model provides a virtual framework that can be adapted for various mentorship opportunities.

11 Exploring the Impact of COVID-19 on Families of Children with Developmental Disabilities: A Community-Based Formative Study

Primary Subject area

Developmental Paediatrics

Background

The COVID-19 pandemic has impacted every facet of society but has been particularly disastrous for families of children with developmental disabilities (DD) living on the margins. The unprecedented repercussions of COVID-19, including quarantine, social distancing, and service restrictions, continue to disproportionately impact these families. This is a pattern observed in previous humanitarian crises, where there has been a lack of response for children with DD. There is an urgent need to understand the experiences of families of children with DD in order to develop a community-driven model of service provision.

Objectives

This study aims to identify the experienced impact of COVID-19 on families of children with DD who have significant needs and social barriers.

Design/Methods

This was a community-based participatory study using a formative research framework in accordance with COREQ guidelines. In-depth interviews (IDIs) were conducted with caregivers and care providers of children with DD. Data were recorded, transcribed, and coded using deductive and inductive coding methods by three independent coders. A peer debriefing strategy was used to verify the coding approach and interpretation of findings in accordance with the RATS (relevancy, appropriateness, transparency, and soundness) guidelines for qualitative research. Perceived parental stress and social support were explored using the Perceived Stress Scale (PSS-10) and Multidimensional Scale of Perceived Social Support (MSPSS).

Results

A total of 25 IDIs were conducted. Of the 15 caregivers interviewed, five were new to Canada. Results suggested both newcomer and non-newcomer families of children with DD are in crisis, reporting high stress and low social support, with increased difficulties navigating and accessing therapies and programs, including those offered virtually. Participants reported behavioural regressions and increased anxiety among their children with DD, as well as caregiver mental health challenges. Providers reported having to change their service delivery model in accordance with public health recommendations, but caregivers said that they were not included in these decisions.

Conclusion

Families of children with DD face extraordinary barriers to care, which may be further compounded by the COVID-19 pandemic. Our study demonstrates the value of community-informed design, particularly in the setting of the COVID-19 pandemic. To deliver truly patient-centred services during the pandemic, there is an urgent need for responsive programming that is built with patients, for patients.

148 A Chair at the Table: A Scoping Review of the Participation of Refugee Adults and Youth in Healthcare Research and Policy Design

Primary Subject area

Global Child and Youth Health

Background

The current refugee crisis is described as the largest humanitarian crisis of all time. Refugees often face psychosocial complexity and multi-dimensional healthcare needs. Community-Based Participatory Research (CBPR) methods have been previously employed successfully in designing health programs for refugee children, youth and their families, and in building strong research partnerships in refugee communities.

Objectives

To review the evidence in the involvement of refugee adults, youth and children in CBPR processes.

Design/Methods

A scoping review was performed, using Arksey & O’Malley’s methodological framework. A literature search in Medline, PubMed, PsycINFO, CINAHL, Embase and Scopus for articles published until August 2020 was conducted. Articles were included if they focused on CBPR or Participatory Action Research as the methodological framework, had refugee involvement and discussed healthcare and health policy. Data extracted included ethno-racial data, country of origin, purpose of CBPR, refugee CBPR involvement and its influence on health care research and policy.

Results

4125 articles were identified in the database searches. After removal of duplicates, 2077 articles underwent title and abstract review by two authors, yielding a kappa-statistic of 0.85. Fourteen studies were included in the final analysis. Of these, 35.7% (5/14) included refugee children/youth in their CBPR methods. The purpose of the CBPR methods for 60% (3/5) of the articles focused on mental health promotion-related strategies. The other 40% (2/5) of articles focused on reproductive health. Eighty percent (4/5) of the studies included refugees in the inception of the research problem and in knowledge translation efforts, whereas none were involved in seeking funding. All studies included refugee participants in the study design and engaging community/recruitment. However, there were varying degrees of involvement of refugees in the data analysis (40%, 2/5), knowledge translation (40%, 2/5) and scale up (20%, 1/5). All studies did not distinguish between the level of CBPR involvement of children and adolescents.

Conclusion

There is scarce literature describing the involvement of refugee children, youth and their families in research. CBPR has been identified as a methodology with the potential to make substantial contributions to improving health and well-being in traditionally disenfranchised population groups. As the needs of refugee communities are so diverse, efforts should be made to include refugees in all stages of the research process. This scoping review demonstrates that levels of involvement in CBPR processes amongst refugee children, youth and adults may not be differentiated, and as such, may conflate their needs and experiences. Barriers to full participation in research processes should be examined further in order to eliminate health disparities and build capacity amongst refugee communities.

A chair at the table: a scoping review of the participation of refugees in community-based participatory research in healthcare

BACKGROUND

Refugees often face psychosocial complexity and multi-dimensional healthcare needs. Community-Based Participatory Research (CBPR) methods have been previously employed in designing health programs for refugee communities and in building strong research partnerships in refugee communities. However, the extent to which these communities are involved remains unknown.

OBJECTIVE

To review the evidence on the involvement of refugees in CBPR processes to inform healthcare research.

METHODS

A scoping review was performed, using Arksey & O'Malley's methodological framework. A literature search in Medline, PubMed, PsycINFO, CINAHL, Embase, Global Health, Scopus, and Policy File Index for articles published until August 2020 was conducted. Articles were included if they focused on CBPR, had refugee involvement, and discussed healthcare/health policy.

RESULTS

4125 articles were identified in the database searches. After removal of duplicates, 2077 articles underwent title and abstract review by two authors, yielding an inter-reviewer kappa-statistic of 0.85. 14 studies were included in the final analysis. The purpose of CBPR use for 6 (42.9%) of the articles was developing and implementing mental health/social support interventions, 5 (35.7%) focused on sexual and reproductive health interventions, 1 (7.1%) focused on domestic violence interventions, 1 (7.1%) focused on cardiovascular disease prevention and 1 (7.1%) focused on parenting interventions. In terms of refugee involvement in the various stages in the research process, 9 (64.3%) articles reported refugees having a role in the inception of the research, no articles reported including refugees in obtaining funding, all articles included refugees in the design of the research study, 10 (71.4%) articles reported having refugees involved in community engagement/recruitment, 8 (57.1%) articles reported involvement throughout the data collection process, 4 (28.6%) articles reported involvement in data analysis, 6 (42.9%) articles reported having refugees involved in knowledge translation/dissemination and 1 article (7.1%) reported having refugees contribute to scale up initiatives.

CONCLUSIONS

CBPR has been identified as a methodology with the potential to make substantial contributions to improving health and well-being in traditionally disenfranchised populations. As the needs of refugee communities are so diverse, efforts should be made to include refugees as partners in all stages of the research process.

Patient-Centered Care for Women: Delphi Consensus on Evidence-Derived Recommendations

OBJECTIVE

Patient-centered care (PCC) could reduce gender inequities in quality of care. Little is known about how to implement patient-centered care for women (PCCW). We aimed to generate consensus recommendations for achieving PCCW.

METHODS

We used a 2-round Delphi technique. Panelists included 21 women of varied age, ethnicity, education, and urban/rural residence; and 21 health professionals with PCC or women's health expertise. Panelists rated recommendations, derived from prior research and organized by a 6-domain PCC framework, on a 7-point Likert scale in an online survey. We used summary statistics to report response frequencies and defined consensus as when ≥85% panelists chose 5 to 7.

RESULTS

The response rate was 100%. In round 1, women and professionals retained 46 (97.9%) and 42 (89.4%) of 47 initial recommendations, respectively. The round 2 survey included 6 recommendations for women and 5 recommendations for professionals (did not achieve consensus in round 1 or were newly suggested). In round 2, women retained 2 of 6 recommendations and professionals retained 3 of 5 recommendations. Overall, 49 recommendations were generated. Both groups agreed on 44 (94.0%) recommendations (13 retained by 100% of both women and clinicians): fostering patient-physician relationship (n = 11), exchanging information (n = 10), responding to emotions (n = 4), managing uncertainty (n = 5), making decisions (n = 8), and enabling patient self-management (n = 6).

CONCLUSION

The recommendations represent the range of PCC domains, are based on evidence from primary research, and reflect high concordance between women and professional panelists. They can inform the development of policies, guidelines, programs, and performance measures that foster PCCW.

Multi-level strategies to tailor patient-centred care for women: qualitative interviews with clinicians

BACKGROUND

Patient-centered care (PCC) is one approach for ameliorating persistent gendered disparities in health care quality, yet no prior research has studied how to achieve patient-centred care for women (PCCW). The purpose of this study was to explore how clinicians deliver PCCW, challenges they face, and the strategies they suggest are needed to support PCCW.

METHODS

We conducted semi-structured qualitative interviews (25-60 min) with clinicians. Thirty-seven clinicians representing 7 specialties (family physicians, cardiologists, cardiac surgeons, obstetricians/gynecologist, psychiatrists, nurses, social workers) who manage depression (n = 16), cardiovascular disease (n = 11) and contraceptive counseling (n = 10), conditions that affect women across the lifespan. We used constant comparative analysis to inductively analyze transcripts, mapped themes to a 6-domain PCC conceptual framework to interpret findings, and complied with qualitative research reporting standards.

RESULTS

Clinicians said that women don't always communicate their health concerns and physicians sometimes disregard women's health concerns, warranting unique PCC approaches.. Clinicians described 39 approaches they used to tailor PCC for women across 6 PCC domains: foster a healing relationship, exchange information, address emotions/concerns, manage uncertainty, make decisions, and enable self-management. Additional conditions that facilitated PCCW were: privacy, access to female clinicians, accommodating children through onsite facilities, and flexible appointment formats and schedules. Clinicians suggested 7 strategies needed to address barriers of PCCW they identified at the: patient-level (online appointments, transport to health services, use of patient partners to plan and/or deliver services), clinician-level (medical training and continuing professional development in PCC and women's health), and system-level (funding models for longer appointment times, multidisciplinary teamwork to address all PCC domains).

CONCLUSIONS

Our research revealed numerous strategies that clinicians can use to optimize PCCW, and health care managers and policy-makers can use to support PCCW through programs and policies. Identified strategies addressed all domains of an established PCC conceptual framework. Future research should evaluate the implementation and impact of these strategies on relevant outcomes such as perceived PCC among women and associated clinical outcomes to prepare for broad scale-up.

[Does coxitis fugax predispose for later Perthes' disease?--first results of an insurance data-based study]

INTRODUCTION

For decades, it has been a matter of debate whether coxitis fugax (CF) may trigger the onset of Perthes' disease (PD). However, the low incidence of both conditions limits the validity of clinical studies. As a novel approach, an analysis of patient data provided by a private health insurance (PHI) was performed. After calculation of the frequencies of CF and PD possible correlations were statistically assessed. We hypothesised that CF predisposes to the development of PD.

MATERIALS

A retrospective database analysis was conducted based on insurance data of patients aged between 1 and 14 years covering an observation period of 7 years. Cases of CF and PD were detected by a search algorithm based on the International Classification System of Diseases (ICD) encoding the ICD codes M12.85 to CF and M91.1 to PD, respectively. Cases where CF was followed by PD were separately assessed for plausibility considering the clinical course and the length of the symptom-free interval. Statistical analysis was performed by using the chi-square test with a significance level set at 5 %.

RESULTS

Among a cohort of 407,875 children 960 cases of CF were detected. Of these, 876 (91.3 %) had one single event of CF whereas 84 (8.7 %) children had two or more episodes. The average incidence of CF was 0.24 % per year. The frequency of PD was calculated to be 15.7 cases per 100, 000 children per year. In eleven cases (all male) CF was found to be followed by PD, however, after checking for plausibility only three cases remained. Statistical analysis revealed that the incidence of PD in male children with a previous CF episode was 21-times higher compared to children without CF (p < 0.0001).

DISCUSSION

The results of the hitherto largest study including more than 400 ,000 children showed a significantly higher rate of PD in male children with previous CF compared to boys without CF. However, different patterns of age distribution and the observation that multiple CF episodes do not trigger the development of PD contradict the assumption of a possible correlation between these two diseases. In two of the three cases where CF was followed by PD a so-called "late onset PD" was evident suggesting a misdiagnosed PD at initial presentation. The chosen study design using patient data provided by a PHI allows the acquisition and evaluation of large numbers of cases which may help to elucidate possible correlations between different medical conditions. To unambiguously answer the hypothesis of this study, the inclusion of additional insurance data is necessary.

[Prospective, randomised study of the Bauer and ALMI approaches concerning MRI findings and muscle-specific blood parameters]

PURPOSE

The purpose of the present study was to evaluate the MRI of the hip musculature as well as specific blood parameters on comparison of the Bauer approach with the minimally invasive ALMI approach.

MATERIAL AND METHODS

We compared two patient groups after total hip replacement, which were operated either via the Bauer or the ALMI approach. All 47 patients had the same cementless hip design. All surgeries were performed by two experienced hip surgeons with experience of more than 1200 ALMI approaches. The patient groups did not differ concerning age, sex or side which was operated on. All MRI were performed in a standardised technique with a Philips Outlook Proview (0.23 Tesla). Patients were scanned preoperatively, within 2 weeks after surgery and at time of follow-up 14 months after surgery. The evaluation of the MRI findings was performed by two independent and blinded examiners. In order to document the muscle damage we documented myoglobin (the day before surgery, 6 hours postoperatively and at the first postop. day) und troponin (6 hours postoperatively).

RESULTS

Preoperatively the male patients showed a significantly larger diameter of the gluteus medius muscle. We also could demonstrate in many patients a fatty degeneration even before surgery. At time of follow-up there was no significant difference between the two patient populations concerning the fatty degeneration. There was also no significant difference concerning the muscle atrophy. Muscle oedema, that was present before surgery, however, was no longer present at the time of follow-up. Two patients even preoperatively showed a lesion of the gluteus medius tendon. The range of the postoperative myoglobin level was high (118-5411 µg/L), in the ALMI group the standard deviation was 1445 µg/L, in the Bauer group it was 738 µg/L. There was no significant difference between both groups. Similar findings were documented for the troponin levels.

CONCLUSION AND CLINICAL RELEVANCE

Even before THR many patients show significant degeneration in the hip muscles. Muscle oedema that was present before surgery had disappeared at the time of follow-up. The fatty degeneration was still present at the time of follow-up. There was no difference concerning the muscle atrophy between the ALMI and the Bauer groups.

[The spinoglenoid ligament - an anatomic study]

PURPOSE

In over-head motion athletes a dysfunction of the suprascapular nerve has been described. In the literature a relation between the spinoglenoid ligament and the dysfunction of the suprascapular nerve is mentioned. An appreciable variability of this ligament is described. The purpose of the present study was the anatomic documentation of the spinoglenoid ligament and its relation to the suprascapular nerve.

MATERIAL AND METHODS

In 36 shoulder specimen the suprascapular nerve, the spinoglenoid and bony parameter of the scapula were documented. The statistic evaluation was performed with SPSS12.0.

RESULTS

In all but one specimen a spinoglenoid ligament was present. In 20 cases (56 %) the infraspinatus muscle inserted at the spinoglenoid ligament. In five cases (14 %) the spinoglenoid ligament reached the glenohumeral joint capsule. In two cases the suprascapular nerve was completely fixed with the ligament, in four cases the perineural soft tissue had a close connection to the ligament. In four cases a branch of the nerve passed through the ligament. All together in 28 % of the specimen there were mechanical conflicts. In one case a ganglion compressed the nerve.

CLINICAL RELEVANCE

Our anatomic study showed in a significant number of cases a possible entrapment of different origins. These findings have implications both for diagnostics and treatment.

Perivascular axillary brachial plexus block and patient positioning: the influence of a lateral, head-down position

The aim of this study was to examine the effect of a 20 degrees Trendelenburg position on the blockade of nerves that exit the brachial plexus proximally in patients undergoing single-injection axillary brachial plexus block. After a pilot study of eight cadavers suggested that a head-down and lateral position would encourage the proximal spread of local anaesthetic, 72 patients undergoing elective surgery were divided into two equal groups: a Supine group and a Modified Position group (lateral position, 20 degrees head-down tilt). Patients were left in the allocated position for 30 min after an axillary block had been performed with alkalinised mepivacaine 1% 49.5 ml. Sensory and motor blockade evaluation showed that there was a significantly higher proportion of axillary nerve (76% vs. 0%, p < 0.001), thoracodorsal nerve (86% vs. 0%, p < 0.001) and subscapular nerve (89% vs. 0%, p < 0.001) blockade in the Modified Position group. Sensory block of the radial nerve was also improved by the modified position (100% vs. 86%, p < 0.05).

Neuronal regeneration after application of radiofrequency energy to collagenous tissue is affected by limb immobilization: an in vivo animal study

Despite widespread use of radiofrequency (RF)-shrinkage, there have been no studies on the influence of RF-energy on neural elements of collagenous tissue. The purpose of this study was to examine the effect of RF-shrinkage on neural structures of capsuloligamentous tissue and the recovery of neural elements under different postoperative treatment protocols. One patellar tendon of 46 New-Zealand-White rabbits was shrunk. Six rabbits were sacrificed immediately postoperative. Twenty rabbits were not immobilized, 10 were immobilized for 3 and 10 were immobilized for 6 weeks. A monoclonal antibody, specific against a neurofilament protein, was used to detect nerves and neural structures. Staining pattern of nerve fibres was significantly altered immediately postoperative. After 3 weeks the number of nerve fibres and bundles decreased significantly in immobilized and non-immobilized limbs. The loss of nerve fibres was significantly less in immobilized limbs. At 6 weeks the number of neural elements in immobilized limbs increased to the level of untreated control tissue. In non-immobilized limbs we found no recovery of neural elements 9 weeks postoperatively. At this time the number of nerve fibres and bundles was still significantly less compared to the untreated control limbs. RF-shrinkage causes significant alteration of neural elements. Under immobilization nerve fibres and bundles reach the level of normal untreated tissue. Careful rehabilitation is important after RF-shrinkage. Not only for biomechanical reasons, but also to allow the neural elements to recover, thermally modified tissue should be protected from normal physiologic loads.

Interindividual reproducibility in perioperative rotational alignment of femoral components in knee prosthetic surgery using the transepicondylar axis

Femoral component malalignment is one of the main causes of persisting anterior knee pain after knee replacement. This study examined interindividual reproducibility in perioperative definition of the transepicondylar axis (TEA) as a reference for measuring the rotational alignment of the femoral component. Eight surgeons experienced in knee prosthetic surgery marked on Thiel-embalmed cadaver specimens the reference points that they would normally use to define the TEA during knee replacement. These were digitized by a video system, and all the spots defined by the surgeon were translated into a reference picture, allowing a digital analysis of the distances between all the spots marked. The maximal distance between the spots that the participants had marked as relevant for the TEA was 13.8 mm at the lateral and 22.3 mm at the medial epicondyle. Projecting all spots marked into one picture resulted in an area of 116 mm2 on the lateral and 102 mm2 on the medial epicondyle. The median range of the fault between two different participants was 6.4 mm on the lateral side (range 13.2 mm) and 9.7 mm on the medial (range 21.6 mm). Because the rotational alignment of the femoral component is extremely relevant for successful implantation of total knee prosthesis, the interindividual discrepancy in defining the TEA as reference is rather high. As this reference line is commonly used, the perioperative variance and the resulting rotational discrepancy of the femoral component must be considered.

[Basic principles and surgical technique of tibio-fibula-plasty in cartilage-bone transplantation]

BACKGROUND

Within the last few years autologous cartilage-bone-grafting is becoming an established standardized procedure in joint surgery. One significant disadvantage of this technique is the harvesting of the bone plugs from the weight-bearing area of the knee joint.

PURPOSE

The tibiofibular articulation is located close to the knee joint that is operated on. This articulation is covered with cartilage. The purpose of this study was to evaluate the question, whether this joint is suitable as a donor site for bone-cartilage transplants.

MATERIAL AND METHODS

Favourable approaches and committing of anatomical landmarks were investigated on 44 fixed tibiofibular joints. In knee extension, the shortest distance between the joint cleft and common fibular nerve was measured. The cartilage thickness and histology of both the fibular and tibial joint surface were documented. The developed surgical approach was evaluated in patients.

RESULTS

Histological and immunohistochemical examination showed hyaline cartilage and type II collagen. The average cartilage thickness was 1.9 +/- 0.29 mm (minimum: 1.5 mm; maximum: 2.6 mm). The peroneal nerve showed an average distance to the tibiofibular joint of 24 mm (minimum: 12 mm; maximum: 30 mm). Different surgical procedures are possible and clinical relevant.

CLINICAL RELEVANCE

The tibiofibular joint contains cartilage, which may be a reasonable donor site even for the elderly patient. Harvesting the graft from this area may avoid iatrogenic damaging of intraarticular weight bearing cartilage of the knee joint.

Ex vivo evaluation of novel miniaturized laser-induced interstitial thermotherapy applicators for effective small-volume tissue ablation

RATIONALE AND OBJECTIVES

For effective small-volume tissue ablation in clinical and experimental settings, smaller laser-induced interstitial thermotherapy (LITT) applicator designs are required. The aim of this study was to compare the ablation properties of recently developed ultrasmall and small to standard LITT applicators.

METHODS

Laser-induced interstitial thermotherapy was performed on liver samples using ultrasmall, small, and standard LITT applicators. Thermotherapy was monitored by magnetic resonance imaging, and lesion sizes were measured for each image. True lesion sizes were then determined macroscopically and by histology.

RESULTS

For continuous laser application over 5 minutes, maximum power settings were 5 W for the ultrasmall and small applicators and 10 W for the standard applicator. Given identical LITT settings, lesion volume measured by magnetic resonance imaging was significantly larger and histological tissue damage was more severe with the ultrasmall and small applicators than with the standard applicator.

CONCLUSIONS

Small and ultrasmall LITT applicators can be used for effective tissue ablation of small target volumes in experimental and clinical applications.

Is there an option for harvesting autologous osteochondral grafts without damaging weight-bearing areas in the knee joint?

Within the past few years autologous osteochondral transplantation has become an established standardized procedure in joint surgery. One significant disadvantage of this technique is the harvesting of the osteochondral grafts from the weight-bearing area of the knee joint. The tibiofibular articulation is located close to the knee joint that is operated on. This articulation is covered with cartilage. The purpose of this study was to evaluate whether this joint is suitable as a donor site for osteochondral grafts. Ten human knee specimens were freed of all soft tissues around the proximal calf. The age of the specimens ranged between 58 and 79 years. Next the tibiofibular articulation was identified, and both the ligaments and the capsule were removed. After opening the joint the tibial- and fibular-sided joint surfaces were inspected and measured. In all specimens the articular surfaces showed good cartilage coverage. In only a single joint did the cartilage macroscopically show degeneration. In all other joints the cartilage surface was in surprisingly good condition, especially considering the age of the specimens. The average diameter of the cartilage surface on the tibial side was 1.7 +/- 0.26 x 1.9 +/- 0.22 cm and on the fibular side 1.6 +/- 0.31 x 1.8 +/- 0.32 cm. This results in an area of cartilage for transplantation of 3.23 cm2 at the tibia and of 2.88 cm2 at the fibula. The total area for cartilage transplantation is 6.11 cm2. The tibiofibular joint contains cartilage, which may be a reasonable donor site even for the elderly patient. Harvesting the graft from this area may avoid iatrogenic damaging of intra-articular weight-bearing cartilage of the knee joint.

Vitamin E reduces platelet adhesion to human endothelial cells in vitro

Although it has been reported that vitamin E (alpha-tocopherol) can reduce platelet adhesiveness and aggregation in vivo, the mechanism is still unknown. Therefore, the aim of the present study was to determine whether incubations of platelet-rich plasma (PRP) with vitamin E influence platelet adhesion to cultured endothelial cells. To exclude blood plasma involvement, also washed platelets were pretreated with alpha-tocopherol. Vitamin E (0.5-1.0 mM) was added to PRP or washed platelets. Endothelial cells in monolayer were incubated with thrombin-activated platelets (1 or 2 U/ml). After 1 hr of incubation, non-adhered platelets were removed and counted. Treating of PRP with alpha-tocopherol inhibited platelet adhesion to endothelial cell monolayer. This effect was dose dependent on concentrations of alpha-tocopherol and thrombin. In our experiments PRP was treated with alpha-tocopherol and endothelial cell monolayer was used as test surface. These findings agree with previous observations on the adhesivity of platelets to synthetic surfaces after dietary vitamin E in healthy volunteers. When washed platelets were incubated with alpha-tocopherol, no significant reduction of adhesion was detectable. As preincubation of washed platelets with alpha-tocopherol does not inhibit platelet adhesion, it may be supposed that the effect of vitamin E does not occur in a directly cellular mechanism. The data suggest that alpha-tocopherol may reduce platelet adhesiveness probably after incorporation by plasma lipoproteins.

Which stabilization technique corrects anatomy best in patients with AC-separation? An experimental study

In ten human cadaveric shoulder specimens four different parameters were documented prior to, and after, dissecting all passive stabilizers. These included the vertical, horizontal and mediolateral acromioclavicular distance, as well as the clavicular rotation. In addition, the same parameters were documented after acromioclavicular (AC) reconstruction using eight different techniques. The results showed a good reconstruction of the vertical ac-distance. Most of the techniques, especially the coracoid-sling procedure, led to a significant anterior displacement of the clavicle in relation to the scapula. To a lesser degree, most of the conventional procedures also resulted in a lateralization of the acromion and/or clavicular rotation. A bone anchor system for distal fixation in the base of the coracoid process and a medialized hole in the clavicle restored anatomy best. This new technique therefore is recommended for anatomical AC-reconstruction.

Computer assisted implantation of the femoral stem in THA - an experimental study

Fourteen femoral stems were implanted either manually by an experienced surgeon or by a robot in fresh human cadaveric femora. The neck-shaft angle, the anteversion, the length of the femoral neck and the gap between stem and bone was measured in each specimen. Implantation by robot showed higher precision in reconstructing the true anatomic situation as well as providing a better press fit.

[Increasing the quality of preoperative planning and intraoperative application of computer-assisted systems and surgical robots--an experimental study]

14 human femurs were scanned by CAT and 3D reconstructed. In every specimen digital documentation of CCD and antetorsion (AT) angle was performed. With a special software package (Orthodoc) virtual preoperative planning for implantation of a cementless total hip alloplasty was undertaken. The specimens were randomised into two groups, one of which had manual and the other one robot implantation of the femoral component. After implantation all specimens were evaluated again by CAT and CCT and AT angle were documented again. The preoperative CCD angle was 126.7 degrees (SD = 4.0) in the manual group and 127.8 degrees (SD = 4.3) in the robodoc group. Postoperatively the angle averaged 131.9 degrees (SD = 0.8) in the manual group and 133.2 degrees (SD = 1.9) in the robodoc group. Significant differences were found for the AT angle in both groups. The preoperative AT angle in the manual group was 31.3 degrees (SD = 8.8), decreasing to 20.5 degrees (SD = 9.5) after implantation. In the robodoc group this angle was 30.9 degrees (SD = 8.0) before and 31.3 degrees (SD = 8.7) after implantation. The difference between pre- and postoperative AT angle averaged 10.8 degrees (SD = 6.4) in the manual group and only 0.4 degree (SD = 0.9) in the robodoc-group.

CONCLUSIONS

With the technique used, preoperative planning in hip alloarthroplasty is much more accurate than with the conventional technique with plain X-ray. The virtual preoperative planning can be transferred to the intraoperative setting with high precision. These factors may lead to an increase in outcome quality.

[Percutaneous bipolar discectomy. Technical principles and initial results with an in vitro model]

In the present study, the effect of bipolar radio-frequency thermocoagulation of intervertebral discs was evaluated in an in vitro model. In fresh human cadaveric thoracic and lumbar motion segments, we applied radio-frequency energy to the intervertebral disc via a variety of different bipolar HF electrodes, while simultaneously recording the temperature of the dorsal longitudinal ligament. All the segments were weighed in a standardised manner prior to and after the procedure. It was found that a combination of coagulation and vaporisation was most suitable for working on the disc. Applying energy for 300 secs resulted in an average weight loss ranging, electrode-dependently, from 0.3 to 0.7 grams, the mean temperature increase in the longitudinal ligament was 0.1 degree C per min.

CLINICAL RELEVANCE

Our experimental data suggest that PBD may be used for the same indications as the laser in the treatment of disc disease.

[Clinical anatomy in surgical education and graduate education]

On the basis of the experience that knowledge of anatomy is not as sound in clinical education as it should be and with a view to the new licensing regulations for physicians, at the Westfälische Wilhelms-Universität Münster, Germany, we established an interdisciplinary anatomical education. Clinical practitioners from 14 different specialties together with anatomists give lessons in applied anatomy accompanying the dissection course, and clinical experienced anatomists guide senior medical students in parallel to the practical courses to refresh their anatomical knowledge. Conjointly clinical practitioners and anatomists initiate, organize and establish meetings in postgraduate surgical education and experimental surgery. All seminars are evaluated and have a very good compliance.

Pars tuberalis specific cells within the pars distalis of the adenohypophysis. An ontogenetic study

Several types of secretory cells of the pars distalis (pd), especially gonadotrophs, are known to occur in the distal pars tuberalis (pt) of the rat. The distribution of the pt-specific cells, however, within the pd has not been investigated in detail and is the subject of this study. Pt and pd of the rat adenohypophysis were investigated at different stages of the peri- and postnatal development by light and electron microscopy using conventional and immunohistochemical staining. The distribution of pt-specific cells changes from a continuous strand of cells extending on the ventral surface to the centre of the pd perinatally to single clusters in the vicinity of the big portal vessels in adult rats. The secretory activity of pt-specific cells within the pd also varies with age. It is highest perinatally, declines in the young rat, and increases again in the adult animal. Functional implications of our observations are discussed especially in relation to the distribution of melatonin-binding pituitary cells.

[Spinal endoscopy in the detection of problems caused by continuous spinal anesthesia]

Continuous spinal anaesthesia has a number of advantages, but there are a number of drawbacks as well: difficulties in threading the catheter, distribution of the local anaesthetics and the development of cauda equina syndrome. Spinaloscopy was done to visualize the fate of catheters during and after their insertion, as well as the distribution of local anaesthetics injected through these fine-bore catheters. METHOD. The studies were conducted in preserved and fresh cadavers donated to the Anatomic Institute for Medical Studies. The spinal column from T12 to S1, together with the back musculature (in order to preserve the normal curvature of the spine) were removed from the cadaver. Spinaloscopy was done with a 4 mm endoscope with a 0 degree optic (Storz, Tutlingen, FRG). All observations were made from the lumbosacral region of the dissected preparation. In this fashion, it was possible to observe the insertion of the spinal needle used to introduce the catheter into the subdural space. The distribution of local anaesthetics injected through a 22-gauge spinal needle or a 28-gauge catheter was shown by injecting 0.5% hyperbaric bupivacaine colored with a small amount of 1% methylene blue. Pictures were taken 15, 30 and 45 s after beginning the injection. RESULTS. Difficulty in threading the catheter: our observations indicate that the difficulty in inserting microbore catheters is most likely due to inserting the needle too far. It is impossible for the catheter to bend and be inserted into the subarachnoid space. In many cases the catheter encountered the anterior wall of the spinal canal and would slide along various structures. Distribution of the drug: the injection is better dispersed with a 22-gauge needle and it completely fills the subarachnoid space. The local anaesthetics injected through the 28-gauge nylon catheter (Kendall Healthcare, Mansfield, Mass.) are distributed in the dependent portions of the spinal canal. If high doses and a high concentration are injected, the distribution pattern may result in an overconcentration in some parts of the subarachnoid space. Possibility of trauma: the catheter stretches around the roots, the potential for trauma is that untoward stress may be applied to the root, either during full insertion of the catheter or during its withdrawal. CONCLUSION. Spinaloscopy was done in a non-fixated anatomic spinal column preparation with a 4 mm 0 degree endoscope (Storz, Tuttlingen, FRG). Based on our observations, we conclude: The catheter should only be inserted 2 cm into the subarachnoid space. This may decrease the risk of malpositioning. After the tip of the catheter has reached the subarachnoid space, the stylet should be with drawn 2 or 3 cm to minimize the risk of nerve injury and/or bleeding.